Beneath the hardscape of a freeway underpass, the homeless seek shelter, bringing with them their tents, sleeping bags, blankets, children, and stigma. Others find beds in shelters or local parks. It could be Los Angeles, New York, Houston, New Orleans, or almost any urban area. Their populations total more than half a million on any one night and nearly 1.5 million during a year. By and large, their presence is scorned.
The filth that accompanies them, spawned by lack of access to water and toilets, results in outbreaks of infectious diseases, such as hepatitis A. They are also more likely to have HIV and tuberculosis and to suffer from injury, chronic diseases, and mental and emotional health problems, including substance abuse. They are more often harmed than they inflict harm.
When these problems become exacerbated, the homeless show up in an emergency department where experts deal with their health issues. Then, however, emergency physicians face an even more difficult problem—how to discharge patients without a home address.
In response to headlines about patient dumping, the California state legislature recently passed and Gov. Jerry Brown signed a bill that spells out rules for discharging homeless patients. It requires:
- Writing a homeless patient discharge plan. As part of this policy, hospitals must discharge a homeless patient to a safe and appropriate location.
- Developing a written plan for coordinating services and referrals for homeless patients with the county behavioral health agency, health care and social services agencies in the region, health care professionals, and nonprofit social services providers to assist in ensuring appropriate homeless patient discharge.
- Offering the patient a meal and weather-appropriate clothing.
- Giving patients needed medicines if the hospital has a retail pharmacy.
- Offering immunizations and screening for infectious diseases.
- Transporting patients to the discharge destination within a maximum of 30 miles or 30 minutes from the hospital.
The California chapter of the American College of Emergency Physicians worked to ameliorate the bill's requirements to make it more appropriate for the emergency department by, for example, limiting transport time to 30 miles or 30 minutes, substantially reducing the burden on the hospital and ED. Institutions can elect to transport the patient further but not across state lines.
“There are many unmet needs for homeless citizens,” said Aimee Moulin, MD, an associate professor of emergency medicine at the University of California Davis and the current president of the California chapter of the ACEP. “Cities and counties have not met those needs. When you put those social needs on the health care system, there will be costs. [This bill] makes it the hospital's responsibility to provide food and clothing.” She called the bill a Band-Aid that does not address the underlying issues.
Nick Sawyer, MD, MBA, a member of the California ACEP board, said the intent of the legislation is good. “It is important to protect this vulnerable population,” he said. “It is particularly pertinent in a state where one-fourth of the U.S. homeless population lives.”
He said it's really about documenting things to ensure that the state can follow up and know what is happening. “Hospitals have to maintain a log of homeless patient discharges and have it readily available. Another thing is we have to have a written plan on how to do these things,” said Dr. Sawyer, an assistant professor of emergency medicine at UC Davis.
The concern is that the effectiveness of all these efforts depends on the resources available. “If we cannot send them to a shelter, what problem is this solving?” he asked.
“One of the hardest parts of my job is telling a patient I have nothing more to offer. A lot of people come to the emergency department seeking help not for medical issues but for socioeconomic ones. I can give you this piece of paper [with referral sources] that may or may not help you, and good luck,” he said, adding that the bill may answer short-term problems with a meal, clothing, prescriptions, and place to sleep that night, but it won't fix homelessness.
“It won't solve the poverty cycle, the lack of mental health and drug abuse resources. It won't stop society from turning a blind eye to these people. I'm hoping this will be a motivating factor,” Dr. Sawyer said.
Dr. Moulin said she is looking at some of the immediate logistical issues. “How do we keep a closet stocked with clothing in all sizes?” she asked, noting that the issue is really societal. “People should not be homeless in the first place. We need to fix the underlying issues that lead to homelessness.”
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Ms. SoRelle has been a medical and science writer for more than 40 years, previously at the University of Texas MD Anderson Cancer Center, the Houston Chronicle, and Baylor College of Medicine. She has received more than 60 awards, including the Texas Human Rights Foundation Award. She has been a contributor to EMN for more than 20 years.